Internal QA Auditor - Hybrid

Summary

Claims Quality Auditor audits claims for manual and automated processed accuracy, coding accuracy, benefit payment, contract interpretation, and compliance with state regulations and internal policies and procedures. Selects claims through random processes and/or other criteria. Being a Claims Quality Auditor, make recommendations to improve quality, workflow processes, policies, procedures, and system configuration. The Claims Quality Auditor will report to the Claim Manager. The Claims Quality Auditor gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work.

Your role in our mission

• Conduct quality audits of manual and automatically processed claims, pre, and post-payments, utilizing appropriate sources of information, including eligibility, enrollment, state contracts, provider and facility contracts, and state and health plan billing manuals.
• Remain current on federal and state payment policies and methodologies and company policies and procedures; monitor public sources to identify, track, and communicate changes. Develops implementation plans for the introduction, adoption, or modification of payment policies based on legislative or regulatory actions or internal decision-making. Monitor state websites and contract changes for impact on claim payments and update audit criteria as necessary. Respond to inquiries from Ohio State Medicaid and internal departments as assigned.
• Analyze errors and determine root causes for the appropriate classification.
• Provide written documentation regarding audit observations and recommend Payee outreach on claim submission errors.
• Analyze and review responses to audit observations and facilitate corrective action plans.

What we're looking for

• Preferred 2+ years of medical claims processing or auditing experience
• Proficient in MS Office.
• Knowledge of Medicare and Medicaid reimbursement rules
• Required understanding of and experience in medical claims payment configuration processes/systems.
• Strong problem-solving capabilities. Ability to perform root cause analysis when determining areas of opportunity to improve results.

What you should expect in this role

Hybrid

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